Vascular injury

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Background

Types

  • Complete Occlusive
    • Transection
    • Thrombosis
    • Embolism
    • Reversible spasm
  • Non-occlusive

Occult Upper Extremity Vascular Injury

Clinical Features

Hard signs

  • Absent distal pulses
  • Signs of distal ischemia
    • Pain, pallor, paresthesia, paralysis, poikilothermia
  • Audible bruit or palpable thrill at injury site
  • Active pulsatile hem
  • Large expanding hematoma
  • Pulsatile hematoma

Soft Signs

  • Small nonexpanding hematoma
  • Peripheral nerve deficit
  • History of pulsatile or significant hemorrhage at time of injury
  • Unexplained hypotension
  • Bony injury (fracture, dislocation, penetration) or proximity penetrating wound

Differential Diagnosis

Extremity trauma

Evaluation

Arterial Pressure Index (API)

  • Doppler-determined arterial sys BP in injured limb divided by pressure in uninjured limb
    • <0.90 abnormal
    • Allows for serial, objective monitoring
    • Only detects obstructive lesions
    • unreliable in proximal injuries, popliteal injuries, shotgun wounds, multiple wounds, shock
    • false negative with deep femoral artery injury

Duplex Doppler

  • S 95-100%; Sp 97-100%; Acc 98-100%
  • Sens for vessel injury, thrombosis, pseudoaneurysm, intimal flap and A-V fistula

Evaluation Algorithm

Hard (>90% risk of arterial injury; 50% require intervention)

  • Immediate arterial exploration without further investigation

Soft (30% risk of arterial injury)

  • API → if < 0.9 obs/admit for 24h, serial API, consider:
    • Doppler U/S
    • CTA
    • Eval of compartment syndrome

Management

  • Emergency vascular surgery consult (General surgery if vascular not available)

Prognosis

Warm Ischemia Time

  • 6 hours (10% irreversible damage)
  • 12 hours (90% irreversible damage)

See Also

References